Provider Demographics
NPI:1346296969
Name:SPORTS EXTRA PC
Entity Type:Organization
Organization Name:SPORTS EXTRA PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHELE
Authorized Official - Middle Name:THERESA
Authorized Official - Last Name:GILSENAN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:732-388-7300
Mailing Address - Street 1:67 WALNUT AVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:CLARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07066-1640
Mailing Address - Country:US
Mailing Address - Phone:732-388-7300
Mailing Address - Fax:732-388-1330
Practice Address - Street 1:67 WALNUT AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:CLARK
Practice Address - State:NJ
Practice Address - Zip Code:07066-1640
Practice Address - Country:US
Practice Address - Phone:732-388-7300
Practice Address - Fax:732-388-1330
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-25
Last Update Date:2007-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ091807Medicare PIN